Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION Citystate C~ntre Building. 709 Shaw Blvd., Pasig City

Healthlme 637-99-99 www.philhealthgov.ph

PHILHEAL TH CIRCULAR No.~.2010

TO ALL ACCREDITED HEALTH CARE PROVIDERS (INSTITUTIONS AND PROFESSIONALS), ALL MEMBERS AND EMPLOYERS, ALL PHILHEALTH OFFICES AND ALL OTHERS CONCERNED

SUBJECT ENHANCED PHILHEALTH CLAIM FORMS

For operational efficiency and to reduce administrative cost for both the Cmporation and its partner stakeholders, the herein attached enhanced Phil.H ealtb Claim Fonns 1, 2 and 3 are issued. These forms shall be used for all types of clai..t11s to include confinements, packages and out-patient services.

For verification purposes, National Tuberculosis Program (NTP) card are still required for all TB­D OTS package clai..tns. P roviders are also advised to fill-out Part II of Clai..tn Form 3 for Maternity Care Package (MCP) claims.

In order to give ample time to prepare and consume old forms, these forms shall be used for all types of rei..tnbursements effective admission date Sep tember 1, 2010.

The new forms to include the guidelines on proper filling-out may be downloaded from the official Cmporate website (wv.'w .philhealth.gov .ph)

All issuances inconsistent hereof are hereby effectively repealed accordingly.

For strict

. AQUINO

Pm ident a d CEO ~

Date signed: ~ k~ ~ (

PhiiHealth

OP-S1 0-29609

IMPORTANT REMINDERS:

P -- ·\'rm may be reproduced and is NOT FOR SALE )

CF1 (Claim Form)

revised February 2010

PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.

For local confinement, this form together with CF2 and other supporting documents should be filed within 60 DAYS from date of discharge.

For confinement abroad, this form together with other supporting documents should be filed within 180 DAYS from date of discharge.

Only one (1) original copy of this Form is required per claim application/avail men!.

All information required in this form are necessary and claim forms with incomplete information shall not be processed.

FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES.

PART 1- MEMBER and PATIENT INFORMATION (Member/Representative to fill out all items with the assistance of the Health Care Provider)

1. PhiiHealth Identification No. (PIN):

3. Name of Member

Last Name First Name Middle Name (example: DelaCruz, Juan Jr., Sipag)

4. Mailing Address:

(House Number & Name of Street) (Barangay)

(City I Municipality) (Province) (ZIP Code)

6. Contact Information (if available):

E-mail Address: Mobile No.:

2. Member Category:

0Employed D Gavemment

DPrlvate

Otndiv ldually Paying

5. Date of Birth:

I I IL-.__L__j (Month) (Day)

Land line No.:

Osponsored

OoFw Outetime

(Year)

----------------------7. Name of Patient

Last Name First Name Middle Name

9. CERTIFICATION OF MEMBER:

(example: DelaCruz, Juan Jr., Sipag)

'a_ 0 Patient is the Member

0 Patient is a Dependent

D Child D Parent

Ospouse

I hereby certifY that the herein information are true am/ correct and may be used for any legal purpose.

Signature Over Printed Name of Member

l__tj-U_j-1 I I I Dale Signed (month-day-year)

11.Reason for Signing on Behalf of the Member:

0Member is Abroad I Out-of-Town

Signature Over Printed Name of Member's Representative

LU-LU-I I I I Dale Signed (month-day-year)

0Member is Incapacitated D Other Reasons:

10.Relationship of the Representative to the Member:

Ochild

ospouse

0Parent

OGuardian I Next of Kin

PART II- EMPLOYER'S CERTIFICATION (for employed members only)

1.Phi1Health Employer No. (PEN):

3. Business Name and Official Address:

{City I Municipality)

4. CERTIFICATION OF EMPLOYER:

L__J__J..__--l.._..L____.__..J____, _ _,___JI - U 2. Contact No.: --------

(Business Name of Employer)

(Building Number and Street Name)

(Province) (ZIP Code)

This is to certifY that allmontltly premium contributions for tmd in behalf of the member, while employed in this company, including the applicable three (3) montlzly premium contributions within the past six (6) months p eriod prior to the first day of this confinement, have been deducted/collected aml remitted to PhiLH ealth, ami that the information supplied by the member or his/Iter represenlllti1>e 011 Part I are consistent with our Ol'ailable records.

___ §19 [1~1 l]r(3_0y_e_r_~rlfl!~d.~amE? . .ofJI!:IP'9Yt3L'!.-~-~~9.~t3~.!3e..ert3?.e.~~Y!L .•. __ ~ ___ _gmc.L?.I_geP.~.'?i~ t.P.~-~igrJ~t.\9.'1 ... , ... _____ __ , ... _ ___ Q,?.I~- -~lgn_(3dJ~C2Jllll·~.?.Y::Y~-~fL (For Phil Health use only) !

,l

I This torn, ,,,ay be reproduced and is NOT FOR SALE

Series #I

IMPORTANT REMINDERS: PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES.

CF2 (Claim Form)

revised February 2010

(For PhiiHoollh uoo only)

For local confinement, this form together with CF1 and other supporting documents should be filed within 60 DAYS from dale of discharge All lnformaOon required In U1ls form are necessary and claim forms wiU1 incomplete information shall not be processed. FALSE /INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL. CIVIL OR ADMINISTRATNE LIABILITIES.

PART I- PROVIDER INFORMATION (Institutional Health Care Provider to fill out Items 1 to 13)

1 Name of Facility:

2. Address:

3. PhiiHeallh Accreditation No. (PAN): (Institutional Health Care Provider)

5. PhiiHeallh Identification No. (PIN): (Member)

6. Name of Patient

Firs! Name

I I I I

Middle Name (example: DeJa Cruz. Juan Jr.. Slpag)

4. Category of Facility:

0 T-L4 /L3 0 ASC 0 RHU

0 S-L2 0 FDC 0 TB DOTS

0 P-L1 0 MCP 0 (OTHERS)

Lasl Name

7. Dale of Birth W - W - I 1 1 I 8. Age l_J Yearls D Monlh/s D Dayls D 9. Sex D Male D Female (month-day-year)

10 Confinement Period

a. Dale Mnilled: W - W - Ll ..t,-i ..J........L-l

(month-day-year)

c. Dale Discharged: W - W - ,_1 ..,_J __._._.

(month-day-year)

b. Time Admilled: l_J AM L_j PM

d. Time Discharged: L_j AM L_j PM

e. No. of Days Claimed L_j

f. In case of Death, specify date

w -w -L.JI iL.......II-L....J (month-day-year)

11 . Health Care Provider Services Actual Charges PhiiHealth Benent For Phil-iealh Use On~ (Adjustments I Remarks)

a. Room and Board Private O ward D

b. Drugs and Medicines ( Part II for details )

c. X-ray/Lab./Supplles & OU1ers (Part Ill for details)

d. Operating Room Fee

TOTAL

e. Benefit Package

12. CaseType· DA Oe De Do 13. CompleteiCD-10Code/s

'This is only applicable for claims with fee for service payment mechanism

(Professional Health Care Providers to fill out Items 14 to 16)

14 Admission Diagnosis 15. Complete Final Diagnosis

16. Professional Fees I Charges

a Name of Professional b. PhiiHeatth Accredilallon No.

c Number oi Visils I RVS Code o. Total Actual f. PhiiHeallh d Inclusive Dates trmo·dci-Ym) PF Charges Benefit I

I I I I 1-1 I I I I I I 1-U

I I I I 1- 1 I I I I I I 1- U

I I I I 1- 1 I I I I I I 1- U

l1 1 1 1- 1 I I I I I I 1-U

,

g. Amount paid h. Signature by members i. Dale Signed

For Phil-iealh Use Only

Preparation J ACtUal I 1 11111._.._,,.,,

Generic/Brand name (doso/ c•ptsyfllp/lnjoctiblc Qty Unit Price Charges Benefit

Aab with mVI1Y,IIgm conlonl)

,,

TOTAL

.. PART Ill- X-RAY, LABORATORIES, SUPPLIES AND OTHERS (use add1t1onal sheet If necessary)

Qty Unit Price Actual Phil Health

Particulars Charges Benefit

A. X-Ray (Imaging)

B. Laboratories/Diagnostics

C . Supplies and Others

TOTAL

0 ..

Official receipts for drugs and mediCines I supplies purchased by member from external sources as well as laboratory procedures do;,e oub:.oJe the hospital which are necessary for the confinement are attached to this c laim.

PART IV - CERTIFICATION OF INSTITUTIONAL HEALTH CARE PROVIDER

I certify thaJ sef'liices rendered were recorded in the patient's chart and lw.~pital records ami thaJ the herein information given are tme and correct.

The foregoing iteiiL~ and charges are in compliance with the applicable laws, ru1es and regulations.

L_j - L_j-1 I I Signature Over Printed Name of Authorized Representative Official Capacity I Designation Date Signed (month-day-year)

PART V- CONSENT TO A CCESS PATIENT RECORD/S

I h ereby consent to the examination by PlzilHea/Jh oftlw patient's medical records for the sole purpose of verifying the veracity of this clainL

I hereby hold PhilHealth or any of its officers, employees a/Ullor representatives free from any and a.llliabi1ities relaJive to the herein-mentioned consent which I have voluntarily and willingly given in cmmection with this claim for reimbursement before PhillfealJ/t.

Signature Over Printed Name of Patient

L..U-LJ - 1 I Date Signed (month-day-year)

Signature Over Printed Name of Patienfs Representative

LJ - LJ - 1 I Date Signed (month-day-year)

Reason for Signing on Behalf of the Patient:

Relationship of the Representative to the Patient

D Spouse 0 Child 0 Parent 0 Guardi::~/ Next oiK1n

D Patient is Incapacitated D Other Reasons: _ _ _ _ __________ ______ _

Thlo ·~rm may be reproduced and Is NOT FOR SALE )

IMPORTANT REMINDERS: THIS FORM SHOULD BE FILEO TOGETHER WITH PHILHEAL TH CLAIM FORMS 1 AND 2 WITHIN 60 CALENDAR DAYS FROM DATE OF DISCHARGE. FOR LEVEL I FACILITY, THIS FORM SHALL BE REQUIRED FOR ALL BENEFIT CLAIMS.

CF3 (Claim Form)

revised February 2010

FOR LEVELS 2, 3 AND 4 FACILITIES, THIS FORM IS REQUIRED IN CASES OF: I) EMERGENCY/TRANSFERRED 2) LESS THAN 24 HOURS ADMISSION 3) CASE TYPE 'D' DIAGNOSIS. THIS FORM SHALL BE REQUIRED FOR ALL CLAIMS ON MATERNITY CARE PACKAGE.

PART 1- PATIENT'S CLINICAL RECORD

1. PhiiHealth Accreditation No. (PAN) - Institutional Health Care Provider:

2. Name of Patient

Last Name, First Name, Middle Name (example: Dela Cruz, Juan Jr., Sipag)

4. Date Admitted: W - W-Itll Month Day Year

5. Date Discharged: W-W-Itll Month Day Year

6. Brief History of Present Illness I OB History:

7. Physical Examination (Pertinent Findings per System )

General Survey:

Vital Signs BP : CR: _ __ RR:

HEENT

ChesVLungs

cvs

8. Course in the Wards (attach additional sheets If necessary):

Time Admitted:

hh·mm

Time Discharged: L__jAM hh-mm

Temperature: _ _ _ _

9. Pertinent Laboratory and Diagnostic Findings: ( CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc. )

hh-mm

Abdomen

GU ( IE)

Skin/Extremities

Neuro Examination

3. Chief Complaint I Reason for Admission:

10. Disposition on Discharge: 0 Improved 0 Transferred D HAMA 0 Absconded 0 Expired

tART II- MATERNITY CARE PACKAGE-~

PRENATAL CONSULTATION

1. Initial Prenatal Consultation W-W- 1111 Month Day

2. Clinical History and Physical Examination

a. Vital signs are normal D D

c. Menstrual History LMP LLJ - lLJ - I 1 1 1 I Age of Menarche ___ _ Month D1y y.,,.

b. Ascertain the present Pregnancy is low-Risk d. Obstetric History G p --- __ , __ , __ , __ T p A L

3. Obstetric risk factors

a. Multiple pregnancy 0 d. Placenta prevta 0 g. History of pre-eclampsia 0 b. Ovarian cyst D e. History of 3 miscarriages D h. History of eclampsia 0 c. Myoma uteri 0 f. History of stillbirth D i. Premature contraction 0

4. Medical/Surgical risk factors

a. Hypertension D D D

d. Thyroid Disorder 0 g. Epilepsy D D D

j. History of previous cesarian section 0 b. Hearl Disease e. Obesity 0 h. Renal disease k. History of uterine myomectomy 0 c. Diabetes f. Moderate lo severe asthma 0 i. Bleeding disorders

5. Admitting Diagnosis

6. Delivery Plan

a. Orientation to MCP/Availment of Benefits DO b. Expected date of delivery W - LLJ - I 1 1 1 yes no Month Day Year

7. Follow-up Prenatal Consultation

a. Prenatal Consultation No.

b. Date of visit tnvrJddlyy)

c. AOG in weeks L_l ___,1 IL_____,I c=JI L_ ___, c:=:J c:=:J c:=:J c._____,l .__I _.I I c:=:J d. Weight & Vital signs:

d.1. Weight

d.2. Cardiac Rate

d.3. Respiratory Rate

d.4 Blood Pressure

d.5. Temperature

DELIVERY OUTCOME

8. Date and Time of Delivery Date LL.J -LL.J -1 I I I Time U AM u i-'M Monlh Day Year hh-mm hh·mm

9. Maternal Outcome: Pregnancy Uterine, -0-b-ste-tr-lc- ln-d-ex- -----A~O~G~by~~~p---- MaMor of D•hv•ry

10. Birth Outcome: Fetal Outcome Sex Birth Weigh! tgrm)

11. Scheduled Postpartum follow-up consultation 1 week after delivery W-W- I 111I Month Day

12. Date and Time of Discharge Date W -W -1 , , Time U AM u i-'M Month Day

13. Perineal wound care

14. Signs of Maternal Postpartum Complications

15. Counselling and Education

Year hh·mm hh-mm

POSTPARTUM CARE

done

D 0

a. Breaslfeeding and Nutrition 0 b. Family Planning 0

16. Provided family planning service to patient (as requested by patient) 0 17. Referred to partner physician for Voluntary Surgical Sterilization (as requested by pt.) 0 18. Schedule the next postpartum follow-up D 19. Certification of Attending Physician/Midwife:

I certify that the above information given in this form are true and correct.

Remarks

Signature Over Printed Name of Attending Physician!Midwife LJ LJ I , I I I

Dale Signed (Month I Day I Year)

I lc:=:J c:=:J c=J c:=:J r=J I lr=J c:=:J c:=J

Presenlalion

APGAR Score

: . ..-

GUIDELINES ON THE PROPER ACCOMPLISHMENT OF REVISED PHILHEALTH

CLAIM FORMS 1, 2, & 3

I. General Guidelines applicable to all Claim Forms:

1. Claim Form 1 (CFl) and Claim Form 2 (CF2) shall be accomplished and submitted for .ALL claim applications except for confinement abroad.

2. All CF shall be accomplished using capi tal letters and by checking the appropriate boxes. All items should be marked legibly by using ballpen or sign pen only.

3. Names should be written starting w1 th last, first and middle name and should be separa ted by :1 comma. Extensions such as (but not limited to the following) Jr., Sr., III should be indicated after the first name.

I 1/ustration:

DELACRUZ, JUAN JR., SIPAG

Last name Fil-st Name .M.iddle ]\Tame 4. .-\ll dates should be filled ou t follm.ving dti s format:

MONTH-DAY-Y£1\R (MM-DD-Y\Yi').

Illurtration:

Jufy 27, 2010 should be IVIitteu as 07/2V2010

5. Time should be filled out using this format: HOUR: JYITNUTE (HHJviM) following the 12-hour convention. I t should be indicated in d1e appropriate box whemer AM (m.orning) or PM (afternoon and evening).

I /lustra/ion:

Nine Jiftem in tbe moming should be wn'tten or 09:15AM

6. Phill-Iealtb Identification No. (PIN) and Phi!Health

Employer No. (PEN) should be filled out

following d1e 2-9-1 format.

I llt1Stration: 12-123456789-1

7. Ph.i.J.Heald1 ,-\ccreditation No. (P:\N) for instinuions and professionals should be filled out follow1ng the prescribed formats.

Illustration .for imtitutiom:

Hospiwls -H12345678, ASC-A12345678, .IVICP-11112345,

TB DOTS- T12345 and FDC- D12345

Il/urtration for proftssionalr: 1234-1234567-1 8. For local confinement, supporting docwnents together

with CFl and CF2 should be filed ·with Phi!Heald1 widlin 60 days from date of discharge, e.g.,:

• Member Data Record • MIS (for indiv1dually paying members) • Phi!Health ID (for OF\\/, Lifetime Membe[ and

Sponsored Program 7v1ember)

II. Specific Guidelines:

A. Claim Form 1 (CFl) CF1 is divided i.n to rwo pans:

Part I -Member and Patient Information requires information about d1e member and patient to ascertain the identity of the member/ patient/ dependent for eligibility to PhilHeald1 benefits.

Part II - Employer's Certification (for employed members' only) provides the basic information about the employer and contains the certification of qual.i fying contributions and correctness of the information supplied by d1e member.

The tables below explain the proper way of accomplishing CF1:

Part I - Member and Patient Information (Member/ Representative to fl.ll ou t items 1 to 11)

Item No.

2

3

4

5

6

Description and Instruction

PbilHealtl1 Identification N u mber (PIN) \\/rite me member's Phi!Health Identification Number (PIN), a 12 digit number, as reflected in the Ph.i!Heald1 Number Card/Identification Card/Member Data Record (MDR).

Illwtration:

07-123456789-1

In case d1e PIN is not known, the member is advised to: a. Inquire from any Phi!Health office; or b. Seek information from employer (for employed

members)

Member Category Check the appropt1.ate box for the current membership categ01y whed1er: Employed (government/ private), Individually Paying; Sponsored; OFW & Lifetime.

Name of Member Wtite me complete name of the member starting with last, first and middle name. It should be separated by a comma. Extensions such as (but not limited to the following) Jr., Sr., III should be indicated after me first name.

11/nstration: Name with Stiffix: , The name J 11011 S ipag De/a Cm:{j Jr. sbonld be 111rit/en ar

DELACRUZ, Last 11ame

JUAN JR., Firrt Name

SIPAG Middle Name

In case the name is different from what is registered with Phi!Health (per :tviDR) the member is advised to attach supporting documents (birth certificate or marriage contract as applicable) for updating of MDR.

Mailing Address (JIJis is the addre.rs 111bere t/;e Benefit Paymmt Notice [BPN] will be mailed to) \"XIri.te the complete address of d1e member, indicating d1e house number, name of street, barangay, municipality or city, province and zip code.

Date of Birth Write the date of bird1 of member follo,:wing the prescribed format for date.

Contact Information \\/rite the member's contact information such as email address, mobile nwnber and land.line number, if available.

N ame of Pa tien t \"!Vrite the complete name of the patient starti11g with

7 last, first md middle name. It should be separated by a comma. Extensions such as (but not !United ro the fo llowing) Jr., Sr., III should be indicated after the first n:lme.

Pa tient is d1e Member If patient is the member, check d1e appropriate box and then proceed to item 9.

Patient is a D ependent If patient is a dependent (to be filled out if patient is dependent)

8 Check the appropriate box if patient is a child, spouse or parent o f the member. Reminder: If patient is legal dependent of the member, the patient's name should appear in the l\IIDR. If not, attach applicable supporting documents as proof of dependency.

Certification of Member Signature over printed n am e of member The member affi"l:es his/her signature over p rinted name certifying d1at all information supplied in P arr I are true and correct and g-ranting consent" to PhilHealth to usc fue supplied u1formation for my legal purpose.

[n case the member is a minor or a survivor-child, a representative Qegal guardian) will also countersign using fue member represen tative portion. If fue legal guardim is nor duly indicated in fue IYIDR, a copy of a judicial order shall be attached to fue claim.

9 D a te signe d T he m ember indicates d1e date when be/ she signed d1e certificate followillg tbe prescribed format for date.

Signature over print ed n am e of membe r's representative An auth orized represen tative of tbe m ember may sign on Ius/her behalf.

D a te signed Th e authorized representati,;e o f d1e patient indicates l11e date when he/she signed on behalf of the patient fo llowing the prescribed format for date.

Rela tionship of the Representative to ilie member 10 Check the appropriate box whed1er the representative

of the mem ber is his/her child (must be 18 years old and above), spouse, parent and guardian/ next of kin.

Reason for signing on b ehalf of the m ember 11 Indicate tbe reason for sign.ing on behalf o f the

member such as: (1) Member is Abroad / O u t-of-Town; (2) Membe1· is incapacitated md (3) Oilier reasons. For other reasons, please specify.

Part II - Employe r's Certification (for employed m e mbers' o nly)

PhilHealth Employer No. (PEN) 1 Write tbe P hilHealtb Emptoyer Number (PEN) as

reflected in the Certi ficate o f Registration (CoR) .

Contact Number 2 Write d1e contact number Qandline and/or mobile

number) of the employer.

Bu s iness N am e and Offici al Add ress: Write tbe Business Name (as reflected in tbe

3 Certificate of Registration (CoR]) of the em ployer m d the official address starting w i.ili buildin g number, street name, city/m unicipality, province and zip code.

Certification o f E mployer (for employed memb ers only)

Signature over printed name of employer/ authorize d represe ntative: The employer or Ius/her au thorized representative shall affix !us/her signature ce11:ifyi.ng that all mon duy premium conui.butions for and in behalf of the

4 m ember, while employed in th eir comp any, including d1c applicable duee (3) montluy prerniwn contributions have b een deducted/ collected and remitted to PhilHealth during the past si.-x (6) m ond1 period prior to l11e first day o f con finement and tl1e information supplied by the m ember or Ius/her representative are con sistent wid1 d1eir available records.

Official c apa city/ designation: T he employer or autlwrized representative shall indicate Ius/her official capacity/ designation.

D a te signed: T he employer/ au fu01-ized representative shall indicate l11e date when he/ sh e signed d1e claim form ill d1e fo llowing the p resc1-ibed format for date.

For PhilHeald1 use only This b ox/ portion shall be for

the u se of PhilHealth.

B . Claim Form 2 (CF2)

Part I - H e alth Care P rovider Info rmation T his portion contains me following information:

a. hospital information needed by P hi.IH ealili to ascertain the hospital accreditation

b. patient information c. confinemen t period d. admission diagnosis and complete final diagnosis e. a summary of healili care ser;rices wi th correspo nding

hospital charges and amount of Phill-Jealili benefit deducted

f. information on me professional health care provider needed by PhilHealth to ascertain the accreditation status

g. summary of services performed with correspon ding RVS codes, inclusive dates, actual professional charges and amount of Phi.lHealm benefit deducted

Part II - Drugs and Medicines This contains me derailed lis t of the medicines and drugs adrn.in.istcred to the patient including generic names,preparation, quantity, unit price and corresponding actual charges and amount of PhilHealth benefit deducted.

Part III - X-R ay, Laboratories, Supplies and Others Tlus contains the derails on the imaging services, laboratory procedures done, supplies used with corresponding quantity and actual charges and amount o f PhilJ{e~th bene fit deducted .

P art IV - C ertification oflnstitutio~al H ealth Care P rovider T his ascertains mat the se.rviccs rendered to the patient are duly recorded in ilie patient's chart and hospital records m d that all information pertaining to me particular claim are true and correct as certified by the authorized representative.

2

P art V- Consent to Access Patient Records Tl:Us contains the consent voluntarily given by the pacient for verification of the veracity of information relative to the evaluation and reimbursement of the claim.

The following tables below explain the proper way of accomplishing CF2:

P art I- HEALTH CARE PROVIDER INFORMATION

Institutional Health Care Provider to fill o ut items 1 to 13

Item Description and In struction No.

Name of Facility 1 Write the complete narne of facility in capital letters

as indicated in the accreditation certificate.

Address 2 Write d1e complete address of d1e facility.

PhilHealth Accreditation No. (PAN) (For Institutional Health Care Provider) Write d1e current accreditation number of the facility.

3 For multiple accreditation, indicate d1e accreditation number of the facility applicable to the benefit claim.

e.g., Hospital A, a tertiary h ospital categorized as accredited hospital and TB DOTS facility, claiming for TB-DOTS package, the PAN for TB-DOTS facility should be written.

Category of Facility Check the appropriate box for the categot-y of the facility wherl1er:

• Tertiary-lA/L3 (T-L4/L3)

• Secondary-Level2 (S-L2)

• P1-immy-Level 1 (P-L1)

• Ambulatory Surgical Clirllc (ASC) 4

• Freestm1ding Dialysis Clirllc (FDC)

• Maten:Uty Care Package provider (MCP)

• Rural H ealth Unit (RHU)

• TB DOTS

• Others (for non-accredited facility) If the facility has multiple accreditations, e.g., accredited hospital and TB DOTS facility, accredited RHU and TB DOTS facility, accredited RHU, TB DOTS facility at1d MCP (3 in 1 accreditation), check rl1e appropriate box applicable to rl1e benefit clainl.

Member's PhilHealth Identification N o. (PIN) 5 (for member)

Write ilie Member's Phi!Health Identification Number (PIN) following the 2-9-1 format.

N ame of Patie nt 6 Write rl1e complete name of ilie patient starting wid1

last, first and middle name. It should b e separated by a comma. Extensions such as (but not linllted to d1e following) Jr. ; Sr., III should be indicated after ilie first name.

D ate of Birth 7 Write ilie date of birth of patient following ilie

prescribed format.

Age 8 W1:ite rl1e age of the patient at d1e time of admission

and check appropriate box whether d1e age is in year/ s, mond1./ s or day/ s.

Sex 9 Check appropriate box whed1er patient is male or

female.

10 Confinement Period 10:t,10b Date Admitted; Time Admitted; 1 Oc,1 Od Date Discharged; Time Discharged

Write the confinement period to include the date and rime of admission and discharge following the prescribed formats for date and time.

For TB-DOTS Package:

• For patient on intensive phase, indicate d1e Registration Date as date admitted (it em lOa) following the prescribed format for date.

• For patient on maintenance phase, indicate d1e Start Date of maintenance phase as date admitted (item 10a) following ilie prescribed format for date.

• Write NA (Not Applicable) in time admitted, date and rime discharged.

For Outpatient Malaria Package:

• Date admitted corresponds to the date of the start of treatment.

• Date disch arged corresponds to the date of the last day of treatment.

• Write NA (Not Applicable) in time admitted and time discharged.

10e No. ofDays Cl aimed Write d1e munber of days claimed. In computing the munber of days claimed exclude ilie day of admission and include the day of discharge.

I//urtration: For in-patient cases: Admission Date: Janual'y 1, 2010 Discharge Date: Janua1y 13, 2010 No. of Days Claimed: 12 Days For out-patient cases: i \drnission Date: J anuaq 7, 2010 Discharge Date: J anuat)' 7, 2010 No. of Days Claimed: 1

10f In case of death, specify date In case of dead1 of patient during confinement period, specify the date of death in the appropriate box following d1.e prescribed format for date.

11 Health Care Provider Services Indicate the amount of the following items accordingly:

• "Actual charges" refers to the total amount charged by the health care provider (HCP) for eve1y benefit item.

• "Phi!Healrl1 benefit" refers to the amount d1at will be r~imbursed to the H CP by Phi!Health. The san}e represents deduction made from d1e patient's actual charge as member's benefit.

11a For item 11a Room and Board, cl1eck appropriate box whether private or ward .

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13

• Private- refers to a single occupancy room or with less than three beds per room divided by either a permanenr or semi-permanent partition.

• Wa.rd- refers ro a room with three or more beds.

For benefit packages not requiring itemization PHIC benefit should be indicated in lle.

Case Type Check the approptiatc box of the correct· illness case type whether A,B,C or D . This is only applicable for claims with fee-for-service payment mechanism.

Complete ICD-10 Codes Wtite d1e complete ICD 10 code/s of d1e patient's diagnosis. T he first code indicated should be the prinuty illness. The succeeding codes shall represent co-morbidities.

Professional H ealth Care Provider to fill out items 14 to 16

14 Admiss ion Diagnosis Write the admission diagnosis.

Complete Final Diagn osis Write the complete final diagnosis of patient's illoess/injmies including the main diagnosis and other co-morbidities.

Provide the following information, as applicable:

a T he etiologic agent (e.g., Escherichia coli) i.n diagnosing infections;

b For benign and malignant tumors, indicate the site, morphology and behaviom.

c. In di11gnosing injmies, provide the nature of the injury, and if possible, d1e place of

15 occmrence and the activity of the one in jured during d1e time of the incident.

d. When diagnosing poisoni.ng or adverse reaction cases, specify the offending agent (e.g., drug, chemical).

e. Specify if a condition IS a late effect or sequelae of another condition (e.g., pulmonaty 'fibrosis sequelae of PTB).

For multiple conditions, the main or primary condition must be the first diagnosis that should be written.

e.g., Patient X is diagnosed with acute pyelonephritis with concomitant hypertension and diabetes Complete Fi11al Diag11oiis: acute bacterial pyelonephritis, hypertension controlkd, diabetes mellitus control.lcd

16 Professiona l Fees/Charges 16a, Name of Accredited Profe ssional and 16b PhilHealth Accreditation No.

16c, 16d

Write the name/s of professional health care provider/s who attended and provided serv1ces to the patient with corresponding PhilHcalth accreditation number/s in the boxes provided.

No. ofVisits / RVS Code and Inclus ive Dates Indicare the fol.IO\ving services rendered to the patient by the professional

Medical Case-• Indicate if daily visits with inclusive dates • Indicate if preoperative inpatient consultation

(CP Clearance) inclusive dates

Surgical case-

• Indicate the appropLiate RVS code and date of operation/procedure.

• _\nesthesia services- Indicate the type of anesthesia services given and date of setvice/ procedure.

Profession al H ealth C are Services Indicate the amount of the following items accordingly:

16e • "Total "-\ctual Professional Fee Charges" refers to the total amotmt of the professional fee charged by the heald1 care professional to the patient before deduction of P hi1Heald1

16f

16g

16h / i

•

Benefit.

"Ph.ill-leald1 benefit" refers to the amount that will be reimbursed to the professional by Ph.iiHealth. The same represents deduction made from the patient's actual charge as member's benefit.

• "t\motmt paid by member" refers to the paymenr made b)' d1e member after deduction of Ph.ill-:Ieald1 benefit. This represents d1e excess ammmt shouldered by the member. I f full payment was made, indicate the amount equivalent to actual professional charges.

Sign ature/Date Signed -

• The professional who actually rendered the services shall sign in the box provided and indicate d1e date o f signing following the prescribed format for date.

P art II - D rugs and Medicines List down drugs and medicines used/ consumed during conli.nement.

• Indicate d1e generic name and the corresponding brand name of d1e drug

I//urtration: amoxicillin (Amoxil); • Indicate corresponding preparation (dose,cap/ tab in

mg; syrup/ suspension in mg/ml; amp/,rial in mg/ ml); • Indicate tqtal quantity used (piece, ampule, vial, e tc);

• Indicate d1e amount per wlit;

• "Actual charges" refers to the actual amount charged by d1e facili ty for evety item.

• "PhilHealth benefit" refers to the to tal amow1t of benefits for all drugs and medicines.

• Indicate the total amount of actual charges and PhilHealth Benefits for all drugs and medicines

• For benefit packages not requiring itemization, only d1e to tal amounr of PJ-IIC benefit should be indicated .

Part III -X-ray, Laboratories, Supplies and Others Indicate all diagnostic procedures (imaging, laboratory tests, etc.) done and supplies and o ther items used during confinement.

• Indicate total number of procedures/items.

• •

•

•

Indicate the amount per item; ".-\ctual charges" refers to dle total amount charged by d1e facility for every item or service rendered;

"PhilHealth benefit" refers to the total amount of "benefits for x-ray, laboratories, supplies and others. Indicate d1e total amow1t for columns A ctual Charges and Ph.ilHealth Benefit

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Note: Check the box provided if official receipts for drugs and medicines / supplies purchased by member from external sources as well as laborat01y procedures done outside the hospital, which are necessary for the confinement, are attached to the claim.

Part IV- Certification of Insti tutional Health Care Provider

Signature over Printed Name of Auth orized Representative

The authorized representative shall write his/her printed name and affL, his/her signature certifying that the services rendered were recorded in the patient's chart and hospital records and the given information given are true and correct.

Official capacity / Designation \Xlrite the official capacity/ designation of the signatory.

Date signed Write the date of signing following the prescribed format for date.

Part V- Consent to Access Patient Records Signature over P rinted Name The patient shall write his/her name and affi.., Ius/her signature signifying consent to PhilHealth's verification of d1e veracity of the information contained in d1e clain1.

Date Signed Write the date of signing following the prescribed format for date.

Signature Over Printed Name of Patient's Representative The authorized representative of d1e patient may sign on behalf of the patient.

Date Signed '\X! rite the date of signing following the prescribed fonnat for date.

Relationship of the Representative to the Patient \XIrite the relationslup of d1e representative to the patient by checking the appropriate box whether spouse, clllld for majority age, parent or guardian/ next of kin.

R eason for Signing on Beh alf of the P atien t Indicate d1e reason for signing on behalf of the patient whether patient is incapacitated or due to od1er reasons (specify).

C. Claim Form 3 (CF3) (To be filled out by accredited Health Care Provider)

Tlus claim form will support d1e li1formation supplied ill the Claim Form 2 and shall be used in the evaluation of proper case type determli1ation especially type D cases, emergency cases and less than 24 hour admissions.

Tlus is mandatory in:

• Level 1 facilities; • Case type D; • Matwuty Care Package; • Emergency/ Transferred cases, and • Less than 24-hour confinement

Part I - Patient's Clinical Record Tlus is the basis of PllllHealth to asceti:ain d1e patient's clillical hist01y, pertinent physical e..'-arnination findillgs, laboratory & diagnostic findings and disposition upon discharge.

Part II Maternity Care P ackage This provides the information about the prenatal consultation, delivet1' outcome and postpartum care of d1e patient.

CF3 is not required in other PhilHealth benefit packages such as Newborn Care Package, Volur1tary Surgical Contraception, Outpatient Malaria and TB-DOTS, regardless of facility level.

The tables below explain the proper way of accomplishing CF3:

Part I Patien t's Clinical Record

Item D escription/Procedure No.

PhilHealth Accreditation Number (PAN) This refers to the current accreditation number of

1 d1e institutional health care provider assigned by Phi1Heald1. For multiple accreditation, mdicate the accreditation number of the facility applicable to ilie benefit claim. Write PAN followmg the prescribed format.

Name of P atient \Xfrite the complete name of the patient starting wiili

2 last, fust and middle name. It should be separated by a comm.a. Extensions such as (but not limited to the following) Jr., Sr., III should be indicated after the first name.

Chief Complaint/ R eason for Admission 3 Indicate patient's chief complaint for seelring

consultation and/ or reason for admission.

Date Admitted Write d1e date when the patient was admitted

4 following d1e preset1bed format for date.

Time Admitted \'(/rite d1e time when the patient was admitted following the prescribed format for time.

Date D ischarged Write the date when d1e patient was discharged

5 ' following d1e preset1bed format for date.

T ime Discharged Indicate d1e time when the patient was discharged following the prescribed format for time.

Brief History of Present I llness Indicate the chronological events of present illness

6 includll1g all signs and symptoms, prompting consultation and subsequent confinement as described by the patient /guardian/illformant.

Physical Examination 7 Indicate the objective findings including pertinent

negative findings per organ system elicited during the conduct of the physical exanlillation.

Course in the Wards 8 Indica te significant changes/progress on d1e patient's

·' condition during confinement. May add additional '

sheets if necessary.

Pertinent Laboratory and Diagnostic Findings 9 Indicate all significant laboratmy results and

diagnostic findings.

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10 Disposition o n Discharge Check the appropriate box for the disposition whether the patient was discharged Improved, Transferred, Home .-\.gainst Medical .-\.dvice (f-L·\i\L-\), .-\bsconded o r Expired.

Pa rt II Maternity Care P ackage (MCP) CF3 Part II shall be accomplished for MCP claims and must be submitted together with CFl and CF2.

I tem D escription / Procedure No .

PRENATAL

Initial Prena tal Consultation 1 Write the date o f the initial p renat:tl consulta cion o f

the patient following the prescribed format for date.

2 Clinical History and Physical Examination

2a Vital s igns arc normal Check the box provided if the vital signs of the patient are normal.

2b Ascertain the present pregnancy is low risk Check the box provided if pr·esent pregnancy is low risk.

2c Menstrual History

Indicate the date of Last Menstrual Period (Ll'viP) following the prescribed format for date and .-\.ge of lvfenarchc.

2d Obstetric H istory

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Write the Obstetric Score of the patienr by indicating the number of pregnancy I pregnancies (G) and the number of pregnancy/ pregt1ancies that reached viability (P). T he next four (4) blanks correspond to pregnancy outcome (Tem1, Pretenll, Abortion and Living)

Illustration: .-\ mother on her third pregnancy has had 2 del.tveries to 1wo (2) live, letm offspring wi th no his1ory of abo rtio n. The obstetric score shall be:

G3P2 (:fQ Q ~)

Obstetric Risk F actors

Check the appropriate box if patient has any of the following obstetric risk fac to rs:

a. Mul tiple pregnane)' b. Ovarian crsr c. i\ lyoma uteci d. Placenta previa e. History of 3 rniscarciages f. History of s Lillbirth g. Histmy o f pre-eclampsia h. His tOt)' of eclampsia 1. Premature contraction

Medical/ Surgical Risk Factors Check the appropriate box if patient has any of the following me::dical/surgtcal risk facrors: ..

a. Hypertension b. Heart Disease c. D iabe tes d. T hyroid disorder e. O besity f. 1\foderate to Severe :\sthma

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6b

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7b

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7d

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g. Epilepsy h. Rena l disease 1. Bleeding disorders J· History of previous caesarian section k. History o f uterirte myomectomy

Admitting Diagnosis Write the admitting diagnosis of the patient.

Delivery Plan

Orientation to MCP / Availment of Benefits

Check the appropriate box whether or not orientation on MCP Package I,-\ vailment of Benefits was provided to the patient.

Expected date of delivery

Write the expected date of delivery follmving the

prescribed format for date.

Follow-up Prenatal Consultation

Prenatal Consultation Number

T lus corresponds to the subsequent prenatal co nsultations of the patient.

Date of visit (MM/ DD / YY) Write the date of prenatal con~ultation as MI'vf/DD /YY.

Illmlralion: The prenatal visit was done on July 26, 2010; the elate should be written as 07/26/10.

Age of Gestation (AOG) in weeks Compute for age of gestation in weeks and wtite in the appropriate box corresp onding to the date of consultation.

Weight & Vital signs Write the weight and vital signs such as cardiac rate, respiratory rate, blood pressure and temperature corresponding to the consultation.

DELIVERY OUTCOME

Date and Time of Delivery Wtite the da te and time o f delivery following d1e prescribed format fo r date and Lime.

Maternal Outcome \'V'ri te the maternal outcome as to:

• Obstetric Index-Indica te the Obsrertic Index e.g., G3P3 (3003)

• AOG by LMP- Indicate the .-\ge of Gestation (.\OG) in weeks based on d1e Last Menstrual Period (LlviP) .

• M anner of Delivery- I ndicate d1e manner o f delivery (NSD, assisted)

• Presenta tio n- Indicate the presenrarion of the ferus (cephalic, breech, com pound)

Birth Outcome \Vritc the birth o utcome of the ferus as ro:

• Fetal Outcome- Indic:lle whether the fetus is alive ("live") or not such as "fetal death" or "stillbird1".

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•

Sex - Indicate the sex o f the fetus w11ether female or male

Birth weight - Indicate rhe birth weight of ferus in grams

. . . • )

· .. . •. . () • APGAR Score -Indicate the APGAR score of

the fetus on the first minute and five (5) minutes thereafter as to Apperu:ance, Pulse, Grimace, Activity and Respiration.

Scheduled Postpartum follow-up con sultation 1 week after d elivery

11 Write the scheduled postparnun and newborn cru:e follow-up consultation following the prescribed format for date.

Date and Time of Discharge 12 Write the date and time when patient was discharged

fo llowing the presctibed fotmats for date and time.

POSTPARTUM CARE

13 Perineal wound care Check the box provided if petineal wound care was done. Write significant findings, if any, in the remarks.

14 Signs of Maternal Postpartum complications Check the box for any sign of maternal postpartum com plications. Write significan t findings, if any, in the remarks.

15 Counselling and Education 15a,15b Breastfeeding and N uuition; Family Planning

Check the box if counselling and education was provided to the p atient on Breastfeeding and Nutrition and Family Plan.ni.ng. Use remarks portion, if any.

Fa mily Planning Service to patient (as requested by patient)

16 Check the box if family planning service was provided to d1e patient as requested. Use remarks portion, if any.

Referred to partner physician for Voluntary Surgical Sterilization (as request ed by patient)

17 Check fue box if patient was referred to partner physician for voluotru:y surgical sterilization as requested. Use remarks portion, if any.

Schedule the ne"-'1 postpartum fo llow-up , 18 Check d1e box if patient was scheduled for the next

postpartum follow-up. Use remarks portion, if any.

Certification of Attending Physician/ Midwife

Signature Over Printed Name of Attending Physician/ Midwife

19 The attending physician or mid,vife writes name and signs certifying that the information provided in the form are true and correct.

D a te signed Write the date of signing following the prescribed format for date.

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